GUIDANCE

Decision Frameworks

Priority actions for differentiated ART delivery in West and Central Africa

“Prioritizing differentiated ART delivery to fast track reaching HIV targets in West and Central Africa” is a policy brief outlining the key actions to scale up differentiated ART delivery for clinically stable clients in West and Central Africa (WCA). The brief is designed to support advocacy with policy makers, funders and programme implementers globally and in WCA.

A supplement to A Decision framework for antiretroviral therapy delivery titled “Prioritizing differentiation ART delivery for clinically stable clients in West and Central Africa” was developed for national and district ART managers, implementing partners, community partners and donors to support scale up of differentiated ART delivery in WCA. In addition to providing an overview of DSD and guidance on prioritization, the supplement outlines a number of case studies from the region.

A Decision Framework for HIV testing services

“A Decision Framework for HIV testing services” is a practical tool to guide HIV programme managers on how to consider HIV testing and linkage services differently. The structured approach to performing the situation analysis and building HIV testing service delivery models is aimed at helping countries reach the first 90.

Differentiated ART delivery for key populations

“A Decision Framework for differentiated antiretroviral therapy delivery for key populations” draws purposeful attention to men who have sex with men, transgender people, people who inject drugs and sex workers. The framework outlines the methodology for identifying specific challenges, deciding what DSD models may solve these challenges and how to systematically adapt or build a differentiated model of ART delivery for a specific key population.

“A Decision Framework for differentiated antiretroviral therapy delivery for children, adolescents and pregnant and breastfeeding women” draws purposeful attention to these specific populations. It is the second of the Decision Framework series and supports how to implement the 2017 “Key considerations for differentiated antiretroviral therapy delivery for specific populations: children, adolescents, pregnant and breastfeeding women and key populations” (see WHO section below for more detail).

Differentiated ART Delivery

This Decision Framework supports how to implement differentiated ART delivery. It provides a background to the principles and a menu of examples. A 5-step plan to guide ART programme managers is outlined and the key “elements” to consider are described along with the “building blocks” of service delivery.

Global Guidance

WHO

The World Health Organization (WHO) provides guidelines, recommendations and key considerations to support differentiated service delivery across the HIV care continuum.

In 2018, the HIV self-testing strategic framework: a guide for planning, introducing and scaling up was released to support uptake of HIV self-testing including the six-step approach to differentiated HIV testing. In July 2017, WHO prequalified the first HIV self-test. WHO has recommended HIV self-testing since November 2016 when they released a supplement guideline on HIV self-testing and partner notification. This supplement was to the 2015 Consolidated guidelines on HIV testing services.

The 2017 Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy also includes differentiated service delivery. This guideline adds recommendations for appropriate packages of care for clients presenting or returning to care with either advanced HIV disease or when clinically well.

The 2017 Key considerations for differentiated antiretroviral therapy delivery for specific populations: children, adolescents, pregnant and breastfeeding women and key populations outlines the rationale for and features of differentiated ART delivery for clinically stable clients in these populations. The document complements A Decision Framework for differentiated antiretroviral therapy delivery for children, adolescents and pregnant and breastfeeding women (see above, Decision Frameworks).

WHO first recommended a a differentiated care approach in the 2016 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.

WHO also has Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations and Consolidated guidelines on person-centred HIV patient monitoring and case surveillance.

GFATM

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) released a toolkit in November 2015 to provide operational guidance to managers of health facilities on implementing differentiated care approaches. GFATM also released their HIV Information Note in July 2019 to provide guidance to applicants developing Global Fund funding requests for the 2020-2022 funding cycle. Differentiated service delivery is highlighted as a key approach for HIV programmes to enhance implementation quality and efficiency.

UNAIDS

The 2019 Global AIDS Update from UNAIDS, Communities at the centre. Defending rights, breaking barriers, reaching people with HIV services, recognizes that an increasing number of countries are using differentiated service delivery models to establish community-based systems for providing services across the cascade and making the 90-90-90 targets a reality. In 2015, UNAIDS partnered with Medécins Sans Frontières (MSF) to release the first in a series of case studies highlighting the need to adapt ART delivery systems to meaningfully include community-based services.

PEPFAR

The 2019 Country Operational Plan (COP) Guidance lists the adoption and implementation of differentiated service delivery models as a minimum requirement for continued support though the United States President’s Emergency Plan for AIDS Relief (PEPFAR) (pg.34). Attention is drawn to the need to focus these models on populations with low retention rates such as children, adolescents, pregnant and breastfeeding women, and key populations (pg.61).

USAID's Supply Chain for Health team has put together an antiretroviral (ARV) planning tool to help countries consider their ARV procurement and supply chain planning for implementing i. “treat all” and ii. longer ART refills, also known as multi-month scripting (MMS).

MSF

Medécins Sans Frontières (MSF) released its first report, Closer to Home, in 2012 (updated version in 2013) on community-based models of ART delivery that it had been piloting for stable clients in sub-Saharan African countries in partnership with country health authorities. Lessons from implementation in Malawi are summarized in the 2015 report Lessons learnt from implementing CAGs in Thyolo, Malawi.

Guidance on how to implement models of differentiated ART delivery are also available from MSF in the Resource Library, including a toolkit for client-managed groups known as Community ART Groups in English and French, a report and toolkit for health care worker managed groups known as Adherence Clubs as well as for Family Clubs and for an out-of-facility model, or PODI, available in English and French.

Up the care cascade, a report and toolkit on ART/TB/PMTCT initiation patient education and counselling from the MSF Khayelitsha project is available for download below.

National Policies

Eswatini

Eswatini's National AIDS Programme’s National Policy Guidelines for Community-centred Models of ART Service Delivery (June 2016) recognize the need for differentiation throughout the treatment pathway and specifically provide guidance for stable client management. They are accompanied by a set of Standard Operating Procedures.

Democratic Republic of the Congo

In 2018, the National HIV/AIDS and STI control programme (PNLS) of the Ministry of Health in the Democratic Republic of the Congo (DRC) developed both an operational plan and an operational manual to implement differentiated service delivery for people living with HIV. It outlines the different context and population-specific models including community ART distribution points (PODI), as recommends 3-6-month ART refills for stable clients. The operational manual also includes guidance for service providers on HIV/TB service integration.

Ghana

The Ghana National AIDS Control Programme (NACP) launched their “Differentiated service delivery for HIV in Ghana: An operational manual” in December 2017 that was developed with a number of collaborators. The manual focuses on the “how” to differentiated HIV care and includes differentiated HIV testing services, differentiated ART initiation and differentiated ART delivery (including for clients with high viral load and for clients with co-infections and co-morbidities). Throughout the document, considerations are provided for specific populations including pregnant and breastfeeding women, children and adolescents, and key populations.

Kenya

Since 2016, the Kenyan Ministry of Health, through the National AIDS & STI Control Programme (NASCOP), has included provision for differentiated service delivery in national guidelines. New guidelines were launched in 2018 including guidance on DSD for clients who have advanced disease and those who are clinically well. To accompany the guidelines and practical handbook, NASCOP released a Differentiated Care Operational Guide in January 2017.

Mozambique

In 2018, the Ministry of Health in Mozambique released guidance on differentiated service delivery with two modules. The first focusses on differentiated prevention and testing services and the second on differentiated ART delivery including community ART groups and family-centred approaches. This guidance compliments the 2015 document Community Adherence and Support Groups Strategy.

Namibia

In December 2016, the Ministry of Health and Social Services in Namibia released the fifth edition of their “National Guidelines for Antiretroviral Therapy” to align with new recommendations from WHO. A new chapter on “Differentiated Care” was included outlining guidance for facility-based and out-of-facility models including fast-track refills, ART Adherence Clubs, outreach and Community ARV refill groups.

Nigeria

In 2016, the Federal Ministry of Health in Nigeria released revised national guidelines for HIV prevention, treatment and care. In addition to recommending that all people living with HIV initiate ART, the guidelines included a chapter on service delivery. In Chapter 9, four broad categories of people living with HIV are outlined as per WHO recommendations. A specific package of care is described for clinically stable clients including three monthly clinical consultations, three monthly ART refills and community ART delivery models.

Rwanda

Rwanda’s “National Guidelines for Prevention and Management of HIV and STIs” were revised in 2016 including section 10 on “differentiated model for ART delivery stable patients”. Stable patients are eligible to receive 3-monthly refills directly from pharmacy and 6-monthly clinical consultations. The policy outlines eligibility criteria for these models and explicitly states that all stable patients from key populations are also eligible.

Sierra Leone

In May 2018, the Ministry of Health and Sanitation in Sierra Leone, with support from UNAIDS, set out their country guidance on differentiated service delivery in the “Guide of differentiated care model in Sierra Leone: Who feels it knows”. The guideline covers the continuum of care from HIV testing to ART delivery for stable clients and highlights differentiation for men, adolescents and key populations. It specifically defines a stable child and differentiated ART delivery models for children and adolescents. It also includes differentiated viral load testing approaches.

South Africa

The South African National Department of Health launched the National Strategic Plan (NSP) for HIV, TB and STIs 2017-2022 on March 31st 2017 which states that all people living with one or more of the three diseases covered by the NSP will have access to differentiated service delivery. A document summarizing the goals and objectives of the new NSP highlights differentiated care as a ‘game-changer’.

In February 2016, the National Department of Health released its Adherence Guidelines for HIV, TB and NCDs which require phased implementation at each ART facility of one or more differentiated ART delivery model.

The Southern African HIV Clinicians Society published guidelines in 2017 recommending strategies to support adolescents and young adults in achieving and maintaining viral suppression. These are the first in sub-Saharan Africa to recognize the need to differentiate service delivery models appropriate for stable or unstable adolescents and young adults in either their first year of treatment or thereafter. In 2017, the Southern African HIV Clinicians Society released a supplement guideline on HIV self-testing.

Tanzania

In a joint effort, the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) and International Training and Education Centre for Health (I-TECH) released HIV Service Delivery Models: Mapping HIV Service Delivery Strategies in Tanzania in 2017. In 2019, the Ministry's National AIDS Control Programme (NACP) launched the National Accelerated Action Plan on HIV testing services along with the National Comprehensive Guidelines on HIV testing services which recommend a differentiated testing approach including special considerations for children and adolescents, pregnant and breastfeeding women, as well as key and other vulnerable populations.

Uganda

At the end of 2016, the Ugandan Ministry of Health published “Consolidated guidelines for prevention and treatment of HIV in Uganda” with additional guidance on differentiated service delivery. Section 9.1 is entitled “Differentiated service delivery” and includes a building blocks approach with models for differentiated HIV testing, care and treatment. See also community client-led ART delivery (CCLAD) and community drug distribution points (CDDPs) for more information.

In October 2017, an implementation guide for DSD for HIV and TB services was launched to support scale up.

Zambia

The Zambian Ministry of Health (MoH) updated their Consolidated Guidelines for Treatment and Prevention of HIV Infection in 2018 expanding on guidelines for differentiated service delivery for clinically stable clients and for people living with advanced HIV disease.

Zimbabwe

The Zimbabwe Ministry of Health and Child Care (MoHCC) released an updated Operational and Service Delivery Manual for the Prevention, Care and Treatment of HIV in Zimbabwe (OSDM) in February 2017. It sets out ‘how’ to implement WHO’s 2016 clinical guidelines, including differentiated service delivery across the entire HIV cascade from testing through to suppression. The manual also includes standard operating procedures (SOPs) and outlines the five step process for deciding how to differentiate service delivery at a district level. To accompany the manual, the Zimbabwe MoHCC also developed the Consolidated HIV and AIDS Job Aide that includes checklists, clinical algorithms and educational tools to support implementation.

A one-size-fits-all model of HIV services does not work for all 37 million people living with HIV today. Differentiated service delivery is a responsive, client-centred approach that simplifies and adapts HIV services across the cascade to better serve individual needs and reduce unnecessary burdens on the health system. More countries are revising their HIV service delivery models and recognize that it is time to deliver differently.

The International AIDS Society (IAS) developed this website in collaboration with: the World Health Organization (WHO); Joint United Nations Programme on HIV/AIDS (UNAIDS); United States President’s Emergency Plan for AIDS Relief (PEPFAR); Centers for Disease Control and Prevention (CDC); United States Agency for International Development (USAID); Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM); Bill & Melinda Gates Foundation (BMGF); Médecins Sans Frontierès (MSF); World Bank; International Community of Women Living with HIV/AIDS (ICW); and members of several ministries of health. The compendium website contains tools and evidence endorsed for use by national HIV programmes and country implementing partners supported by the agencies engaged in its development.